Cycle 1
Health 2026-01-09 · Fire 2026-01-09
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Meadowbrook, PA
St Joseph's Manor
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1616 Huntingdon Pike, Meadowbrook, PA
(215) 938-4000
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
296
Certified beds
Average residents
204
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.22
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.70
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
4.45
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
366
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
71.74
Composite VBP score used to determine payment impact.
Payment multiplier
1.0232
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.32
Baseline 17.97% · Performance 17.11% · Measure score 9.32 · Achievement 9.32 · Improvement 8.62
Healthcare-associated infections
9.22
Baseline 4.71% · Performance 5.08% · Measure score 9.22 · Achievement 9.22 · Improvement 0
Total nurse turnover
7.38
Baseline 33.82% · Performance 33.51% · Measure score 7.38 · Achievement 7.38 · Improvement 0
Adjusted total nurse staffing
2.78
Baseline 4.01 hours · Performance 3.87 hours · Measure score 2.78 · Achievement 2.78 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.21% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 359 · Observed rate 9.47% · Lower 95% interval 8.25% |
| Discharge to community | 64.57% |
50.57%
14 pts better
|
Better than the National Rate · Eligible stays 334 · Observed rate 61.98% · Lower 95% interval 60% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 90.04% |
95.27%
5.2 pts worse
|
Numerator 217 · Denominator 241 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 241 |
| Discharge self-care score | 53.33% |
53.69%
0.4 pts worse
|
Numerator 104 · Denominator 195 |
| Discharge mobility score | 39.49% |
50.94%
11.4 pts worse
|
Numerator 77 · Denominator 195 |
| Pressure ulcers or injuries, new or worsened | 4.98% |
2.29%
2.7 pts worse
|
Numerator 12 · Denominator 241 · Adjusted rate 5.74% |
| Healthcare-associated infections requiring hospitalization | 5.08% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 198 · Observed rate 2.02% · Lower 95% interval 3.15% |
| Staff COVID-19 vaccination coverage | 1.1% |
8.2%
7.1 pts worse
|
Numerator 3 · Denominator 273 |
| Staff flu vaccination coverage | 90.93% |
42%
48.9 pts better
|
Numerator 331 · Denominator 364 |
| Discharge function score | 50.77% |
56.45%
5.7 pts worse
|
Numerator 99 · Denominator 195 |
| Transfer of health information to provider | 94.29% |
95.95%
1.7 pts worse
|
Numerator 33 · Denominator 35 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 153 · Denominator 153 |
| Resident COVID-19 vaccinations up to date | 19.33% |
25.2%
5.9 pts worse
|
Numerator 29 · Denominator 150 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.7
0.6 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
86.9%
5.9 pts better
|
93.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 93.3% · Q3 92.6% · Q4 93.0% · 4Q avg 92.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
93.5%
0.6 pts better
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.2% · Q3 3.1% · Q4 3.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
6.5%
5.4 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 2.6% · Q4 1.3% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
6.5%
2.3 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.6% · Q3 2.0% · Q4 5.6% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
19.9%
4.1 pts better
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 17.3% · Q3 19.0% · Q4 11.8% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
18.7%
7.8 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 13.2% · Q3 9.6% · Q4 9.4% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.5% |
19.6%
3.9 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 24.9% · Q3 15.4% · Q4 32.8% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.2% |
18.3%
5.9 pts worse
|
14.9%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 18.9% · Q3 21.4% · Q4 36.6% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.7%
0.3 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 1.9% · Q4 2.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
26.4%
3.9 pts better
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 33.9% · Q3 14.5% · Q4 17.4% · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
5.3%
4.5 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 11.9% · Q3 8.9% · Q4 5.6% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.6% |
68.9%
16.3 pts worse
|
81.7%
29.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 59.4% · Q2 54.6% · Q3 46.6% · Q4 52.3% · 4Q avg 52.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
9.8%
2.8 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 5.9% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.4% · Q3 0.4% · Q4 0.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 26.2% |
68.7%
42.5 pts worse
|
79.7%
53.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 26.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
23.1%
3.4 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 22.8% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-02-13 · Fire 2025-02-13
2 health deficiencies
Top issue: Administration (1 deficiency)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2024-02-02 · Fire 2024-02-02
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-12
E · Potential for more than minimal harm
2026-01-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-12
E · Potential for more than minimal harm
2026-01-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-02-12
E · Potential for more than minimal harm
2026-01-09
K924 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that anesthesia apparatus are tested after any adjustment, modification or repair.
Corrected 2026-02-12
F · Potential for more than minimal harm
2025-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-13
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-28
C · Minimal harm
2025-02-13
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-03-28
C · Minimal harm
2025-02-13
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-03-28
C · Minimal harm
2025-02-13
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-03-28
C · Minimal harm
2025-02-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-28
C · Minimal harm
2025-02-13
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-02-02
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-02
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-16
D · Potential for more than minimal harm
2025-04-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-02-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-13
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-02-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-15
Penalties and ownership
What sits behind the stars
Ownership
Brooks, Ronald
Corporate Director · Individual
Dupree, Beth
Corporate Director · Individual
Fallon, Brian
W-2 Managing Employee · Individual
Friel, Donald
Corporate Officer · Individual
Harris, Thomas
Corporate Officer · Individual
Harris, Thomas
W-2 Managing Employee · Individual
Ito, Ellyn
Corporate Director · Individual
Keen, Michael
Corporate Officer · Individual
Keen, Michael
W-2 Managing Employee · Individual
Lezzi, S Nicholas
Corporate Director · Individual
Lynch, James
Corporate Director · Individual
Mcelwain, Guy
Corporate Director · Individual
Mckinnes, Charlotte
Corporate Director · Individual
Peoples, Cristina
Corporate Officer · Individual
Peoples, Cristina
W-2 Managing Employee · Individual
Ragg, Joseph
Corporate Director · Individual
Rodgers, James
Corporate Director · Individual
Sasso, William
Corporate Director · Individual
Singh, K Kultar
Corporate Director · Individual
Walsh, Robyn
Corporate Director · Individual
Wozniak, Gregory
Corporate Director · Individual
Wozniak, Gregory
Corporate Officer · Individual
Wozniak, Gregory
W-2 Managing Employee · Individual
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